Diastasis Recti {An Orthopedic Perspective}

I graduated from The University of Tennessee Memphis with a Doctorate of Physical Therapy Degree in 2004.  At that time, what I knew about postpartum recovery was very limited. In fact, I remember briefly covering the topic of Diastasis Recti Abdominis in one of my Orthopedic labs, but I didn’t give it much thought at the time.  It sounded like something that would really only happen to women carrying multiples or maybe moms that had delivered ten kids. I never dreamed it would happen to me.

In 2007, I became a Board Certified Orthopedic Clinical Specialist. My career up to that point had focussed on the spine and pelvis with an emphasis on manual therapy.   Over the last decade, I have had to opportunity to treat various Orthopedic conditions, but my own journey through postpartum rehabilitation has shaped me as a clinician more than anything else.

I was a college athlete and prior to having my babies, I ran half marathons and worked out consistently.  I would have considered myself very lean and fit. The thought of navigating a diastasis or any other postpartum impairment never crossed my mind.  I now spend a lot of time educating prenatal and postnatal moms on the various orthopedic considerations that are involved with pregnancy, delivery, and recovery.

Diastasis Recti Abdominis, known as DR or DRA, is one of those orthopedic considerations.  DR is a condition in which the abdominal muscles separate. It is a normal process for the rectus muscles to separate during pregnancy, and in most cases, the two sides of the muscle bellies will come back together.  A lot of women become aware of their DR when they notice that they still look pregnant months after having their baby. Some moms will have a routine check for a DR at their six week postpartum visit, and if a separation is found, they might be referred to a physical therapist.  I have seen a number of online programs marketed to moms with DR. Many of them claim to close the gap between their abs with a list of exercises. Some of them instruct moms on the “unsafe” exercises that they should avoid.

As an Orthopedic Clinical Specialist, I tend to look at the mom with a DR through a different lens.  I think about my high school soccer player who tore her ACL or one of my elite runners who is recovering from a spine surgery.  You may be wondering what they could possibly have in common with a postpartum patient, but I would argue that the list of impairments are strikingly similar.

Evidence based research tells us that the gap between a moms abdominal muscles may not be as significant to her full recovery as once believed.  In fact, some studies indicate that women often have a space between their abdominals prior to pregnancy and delivery. With all the focus on the gap between her abdominal muscles, I think we lose sight of treating her as a “WHOLE” patient.  I think we may be overlooking all the orthopedic considerations still present.

An analogy that I use a lot is the recovery process between my postoperative ACL reconstruction patient and my postpartum patient.  I would never send my post operative high school soccer player home with a plan of care to do quad sets for six weeks. I would never expect her to be ready to return to her high level athleticism because six weeks of time had passed.  What I have learned over the years treating patients with ACL reconstruction, is that the quicker she starts rehab, the better her outcomes will be. I want to make sure her muscles engage properly and fire correctly. Then, I want to strengthen not just her knee, but her whole body.  I want to challenge her kinetic chain and her core. I want to make sure she has good balance and proprioception. Before I release her to play soccer, I want to see her jump and perform agility and plyometric drills. I am treating her whole body. I am not just focusing on her knee.

As I have gone through my own recovery for DR and umbilical hernia, what has been eye opening to me, is that my whole body needed to be rehabilitated .  My plan of care has focussed on postural strengthening because my rib cage expanded and my spine and pelvis went through incredible changes as my body grew and carried my babies.  I had to focus on rebuilding my glute strength and my pelvic floor due to the demands of pregnancy, labor, and delivery. I had to retrain my breathing and learn how to connect with my core so that I could get out of bed, lift my children, and carry things without straining my back.  I had to learn how to manage my intra-abdominal pressure while working out so that my DR could begin to heal. I had to spend a lot of time learning how to modify my workouts while breastfeeding and as my body slowly got stronger through progressive overload. I had to learn how my hormones affected the integrity of my connective tissues and develop strategies to manage those areas of connective tissue weakness.  

I believe there is a gap in our healthcare system for women, and I am passionate about seeing that change.  I believe it should be standard of care for moms to have a Prenatal Physical Therapy Visit as well as a Postnatal Physical Therapy Visit.  Pelvic Floor Physical Therapy should be the norm for every mom that delivers a baby. It should not be an afterthought or a last option prior to surgical intervention.

My hope is to see every mom educated on the changes her body will go through during her pregnancy.  I hope she understands laboring positions and delivery options that will minimize trauma to her pelvic floor.  I want her to be instructed in exercise modifications throughout her pregnancy and postpartum recovery and have the knowledge to know how to determine what movements and exercises are “safe.”  My desire is for every mom to be fully equipped for her pregnancy and postpartum recovery and that it will involve a plan that treats her whole body.